{ "hospital_name": "Utah Valley Specialty Hospital Inc dba Central Utah Rehabilitation Hospital", "last_updated_on": "2026-07-01", "version": "3.0.0", "location_name": [ "Utah Valley Specialty Hospital Inc dba Central Utah Rehabilitation Hospital" ], "hospital_address": [ "306 West River Bend Lane, Provo, UT 84604" ], "license_information": { "state": "UT" }, "type_2_npi": [ "1790551794" ], "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": "Manual therapy 1/> regions", "code_information": [ { "code": "97140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Pt eval mod complex 30 min", "code_information": [ { "code": "97162", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A0803", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B0803", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A0804", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B0804", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A0805", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B0805", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 3", "code_information": [ { "code": "D0805", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A0901", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B0902", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 2", "code_information": [ { "code": "C0902", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B0903", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": 24634.05, "10th_percentile": 24634.05, "90th_percentile": 24634.05, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "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": 24634.05, "maximum": 24634.05 } ] }, { "description": "Ther ivntj ea addl 15 min", "code_information": [ { "code": "97130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Aquatic therapy/exercises", "code_information": [ { "code": "97113", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Oral function therapy", "code_information": [ { "code": "92526", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Ot eval mod complex 45 min", "code_information": [ { "code": "97166", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Ther ivntj 1st 15 min", "code_information": [ { "code": "97129", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Pt eval low complex 20 min", "code_information": [ { "code": "97161", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Hemodialysis one evaluation", "code_information": [ { "code": "90935", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Self care mngment training", "code_information": [ { "code": "97535", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Unlisted special svc px/rprt", "code_information": [ { "code": "99199", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Speech sound lang comprehen", "code_information": [ { "code": "92523", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Pt eval high complex 45 min", "code_information": [ { "code": "97163", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Evaluate swallowing function", "code_information": [ { "code": "92610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Ot eval low complex 30 min", "code_information": [ { "code": "97165", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Cognitive test by hc pro", "code_information": [ { "code": "96125", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Appl modality 1+estim ea 15", "code_information": [ { "code": "97032", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ot eval high complex 60 min", "code_information": [ { "code": "97167", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Glucose other fluid", "code_information": [ { "code": "82945", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavral qualit analys voice", "code_information": [ { "code": "92524", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Debride nail 6 or more", "code_information": [ { "code": "11721", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "App mdlty 1+ultrasound ea 15", "code_information": [ { "code": "97035", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Massage therapy", "code_information": [ { "code": "97124", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Glucose blood test", "code_information": [ { "code": "82962", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assessment of aphasia", "code_information": [ { "code": "96105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_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 Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Physical performance test", "code_information": [ { "code": "97750", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam chest 1 view", "code_information": [ { "code": "71045", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Evaluate speech production", "code_information": [ { "code": "92522", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Use of speech device service", "code_information": [ { "code": "92609", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Wheelchair mngment training", "code_information": [ { "code": "97542", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Endoscopy swallow (fees) vid", "code_information": [ { "code": "92612", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Vent mgmt inpat subq day", "code_information": [ { "code": "94003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Orthotic mgmt&traing 1st enc", "code_information": [ { "code": "97760", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "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": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ot re-eval est plan care", "code_information": [ { "code": "97168", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "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": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "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": 100, "maximum": 100 } ] }, { "description": "Electric stimulation therapy", "code_information": [ { "code": "97014", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "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": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Orthc/prostc mgmt sbsq enc", "code_information": [ { "code": "97763", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "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": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 w/auto diff wbc", "code_information": [ { "code": "85025", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pt re-eval est plan care", "code_information": [ { "code": "97164", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "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": 100, "maximum": 100 } ] }, { "description": "Canalith repositioning proc", "code_information": [ { "code": "95992", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Comprehen metabolic panel", "code_information": [ { "code": "80053", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sensory integration", "code_information": [ { "code": "97533", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Community/work reintegration", "code_information": [ { "code": "97537", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Metabolic panel total ca", "code_information": [ { "code": "80048", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ndl insj w/o njx 3+ musc", "code_information": [ { "code": "20561", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ndl insj w/o njx 1 or 2 musc", "code_information": [ { "code": "20560", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Blood gases w/o2 saturation", "code_information": [ { "code": "82805", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "App mdlty 1+iontphrsis ea 15", "code_information": [ { "code": "97033", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Paraffin bath therapy", "code_information": [ { "code": "97018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Complete cbc automated", "code_information": [ { "code": "85027", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct head/brain w/o & w/dye", "code_information": [ { "code": "70470", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Renal function panel", "code_information": [ { "code": "80069", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam chest 2 views", "code_information": [ { "code": "71046", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Extremity study", "code_information": [ { "code": "93970", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ex for speech device rx 1hr", "code_information": [ { "code": "92607", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Vent mgmt inpat init day", "code_information": [ { "code": "94002", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Blood typing rbc antigens", "code_information": [ { "code": "86905", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Resp virus 12-25 targets", "code_information": [ { "code": "87633", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Procalcitonin (pct)", "code_information": [ { "code": "84145", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of magnesium", "code_information": [ { "code": "83735", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sbsq hosp ip/obs moderate 35", "code_information": [ { "code": "99232", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Application of finger splint", "code_information": [ { "code": "29130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prosthetic traing 1st enc", "code_information": [ { "code": "97761", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mechanical traction therapy", "code_information": [ { "code": "97012", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri lumbar spine w/o & w/dye", "code_information": [ { "code": "72158", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct abd & pelv w/contrast", "code_information": [ { "code": "74177", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Unlisted e&m service", "code_information": [ { "code": "99499", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Caregiver traing 1st 30 min", "code_information": [ { "code": "97550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prothrombin time", "code_information": [ { "code": "85610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of natriuretic peptide", "code_information": [ { "code": "83880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Blood culture for bacteria", "code_information": [ { "code": "87040", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sbsq hosp ip/obs sf/low 25", "code_information": [ { "code": "99231", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Medicaid (State)", "plan_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 Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "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": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "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": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Room & Board - Private (One Bed) - Rehabilitation", "code_information": [ { "code": "0118", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1800, "methodology": "per diem", "median_amount": 1800, "10th_percentile": 1800, "90th_percentile": 1800, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 1200, "methodology": "per diem", "median_amount": 1200, "10th_percentile": 1200, "90th_percentile": 1200, "count": "1 through 10" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_dollar": 1600, "methodology": "per diem", "median_amount": 1600, "10th_percentile": 1600, "90th_percentile": 1600, "count": "1 through 10" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_dollar": 1600, "methodology": "per diem", "median_amount": 1600, "10th_percentile": 1600, "90th_percentile": 1600, "count": "1 through 10" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_dollar": 1591, "methodology": "per diem", "median_amount": 1591, "10th_percentile": 1591, "90th_percentile": 1591, "count": "1 through 10" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "PPO", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "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 Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 1200, "maximum": 1800 } ] }, { "description": "Physical Therapy - General Classification", "code_information": [ { "code": "0420", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "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": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Physical Therapy - Visit Charge", "code_information": [ { "code": "0421", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "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": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Physical Therapy - Hourly Charge", "code_information": [ { "code": "0422", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Physical Therapy - Group Rate", "code_information": [ { "code": "0423", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Physical Therapy - Evaluation or Re-evaluation", "code_information": [ { "code": "0424", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "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": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Physical Therapy - Treatment", "code_information": [ { "code": "0425", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Physical Therapy - Continuation", "code_information": [ { "code": "0426", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Physical Therapy - Observation/Hourly", "code_information": [ { "code": "0427", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Physical Therapy - Other", "code_information": [ { "code": "0428", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Physical Therapy - Other", "code_information": [ { "code": "0429", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Occupational Therapy - General Classification", "code_information": [ { "code": "0430", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "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": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Occupational Therapy - Visit Charge", "code_information": [ { "code": "0431", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Occupational Therapy - Hourly Charge", "code_information": [ { "code": "0432", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Occupational Therapy - Group Rate", "code_information": [ { "code": "0433", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Occupational Therapy - Evaluation or Reevaluation", "code_information": [ { "code": "0434", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "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": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Occupational Therapy - Treatment", "code_information": [ { "code": "0435", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Occupational Therapy - Continuation", "code_information": [ { "code": "0436", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Occupational Therapy - Observation/Hourly", "code_information": [ { "code": "0437", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Occupational Therapy - Other", "code_information": [ { "code": "0438", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Occupational Therapy - Other", "code_information": [ { "code": "0439", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Speech Therapy - Language Pathology - General Classification", "code_information": [ { "code": "0440", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "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": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Speech Therapy - Language Pathology - Visit Charge", "code_information": [ { "code": "0441", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Speech Therapy - Language Pathology - Hourly Charge", "code_information": [ { "code": "0442", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Speech Therapy - Language Pathology - Group Rate", "code_information": [ { "code": "0443", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Speech Therapy - Language Pathology - Evaluation or Reevaluation", "code_information": [ { "code": "0444", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "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": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Speech-Language Pathology - Treatment", "code_information": [ { "code": "0445", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Speech-Language Pathology - Continuation", "code_information": [ { "code": "0446", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Speech-Language Pathology - Observation/Hourly", "code_information": [ { "code": "0447", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Speech-Language Pathology - Other", "code_information": [ { "code": "0448", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "Speech Therapy - Language Pathology - Other", "code_information": [ { "code": "0449", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "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": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "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": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Therapeutic exercises", "code_information": [ { "code": "97110", "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": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "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": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "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": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "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": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "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": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "LifePrint Health dba Optum Care", "plan_name": "Medicare Advantage", "standard_charge_dollar": 100, "methodology": "fee schedule", "median_amount": 100, "10th_percentile": 100, "90th_percentile": 100, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 100, "maximum": 100 } ] }, { "description": "X-ray exam of ankle", "code_information": [ { "code": "73610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "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 Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Medicaid (State)", "plan_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 Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hepatitis b surface ag ia", "code_information": [ { "code": "87340", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free assay (ft-3)", "code_information": [ { "code": "84481", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reagent strip/blood glucose", "code_information": [ { "code": "82948", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hemoglobin glycosylated a1c", "code_information": [ { "code": "83036", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "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": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 2", "code_information": [ { "code": "C0407", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 3", "code_information": [ { "code": "D0407", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B0503", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A0504", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B0504", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B0505", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 3", "code_information": [ { "code": "D0505", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A0601", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B0602", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A0603", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B0603", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 3", "code_information": [ { "code": "D0603", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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- Tier None", "code_information": [ { "code": "A0604", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 28945.66, "10th_percentile": 28945.66, "90th_percentile": 28945.66, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "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": 28945.66, "maximum": 28945.66 } ] }, { "description": "Neurological M <43.50- Tier Tier 1", "code_information": [ { "code": "B0604", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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- Tier Tier 2", "code_information": [ { "code": "C0604", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 34214.37, "10th_percentile": 34214.37, "90th_percentile": 34214.37, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 34214.37, "10th_percentile": 34214.37, "90th_percentile": 34214.37, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 34214.37, "maximum": 34214.37 } ] }, { "description": "Neurological M <43.50- Tier Tier 3", "code_information": [ { "code": "D0604", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A0701", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B0702", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B0703", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A0704", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": 29355.06, "10th_percentile": 29355.06, "90th_percentile": 29355.06, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "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": 29355.06, "maximum": 29355.06 } ] }, { "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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 3", "code_information": [ { "code": "D0704", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": 32124.96, "10th_percentile": 32124.96, "90th_percentile": 32124.96, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "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": 32124.96, "maximum": 32124.96 } ] }, { "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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 <44.5- Tier None", "code_information": [ { "code": "A0904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 <44.5- Tier Tier 1", "code_information": [ { "code": "B0904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 <44.5- Tier Tier 2", "code_information": [ { "code": "C0904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 <44.5- Tier Tier 3", "code_information": [ { "code": "D0904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A1001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 2", "code_information": [ { "code": "C1004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 3", "code_information": [ { "code": "D1004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": 32869.99, "10th_percentile": 32869.99, "90th_percentile": 32869.99, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "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": 32869.99, "maximum": 32869.99 } ] }, { "description": "Amputation non-lower extremity M >=58.50- Tier None", "code_information": [ { "code": "A1101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "A1204", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "INJECTION, ADALIMUMAB, 20 MG", "code_information": [ { "code": "J0135", "type": "HCPCS" }, { "code": "00074-0124-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2, "type": "EA" } }, { "description": "Inj ivig privigen 500 mg", "code_information": [ { "code": "J1459", "type": "HCPCS" }, { "code": "44206-0436-05", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Gamunex-c/gammaked", "code_information": [ { "code": "J1561", "type": "HCPCS" }, { "code": "13533-0800-12", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "ML" } }, { "description": "Octagam injection", "code_information": [ { "code": "J1568", "type": "HCPCS" }, { "code": "00069-6002-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 20, "type": "ML" } }, { "description": "Romiplostim injection", "code_information": [ { "code": "J2796", "type": "HCPCS" }, { "code": "55513-0221-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Alteplase recombinant", "code_information": [ { "code": "J2997", "type": "HCPCS" }, { "code": "50242-0041-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "EA" } }, { "description": "Health Insurance Prospective Payment System (HIPPS) - Inpatient Rehabilitation Facility", "code_information": [ { "code": "0024", "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": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": 23439.05, "10th_percentile": 23439.05, "90th_percentile": 23439.05, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "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": 23439.05, "maximum": 23439.05 } ] }, { "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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": 28396.11, "10th_percentile": 28396.11, "90th_percentile": 28396.11, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "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": 28396.11, "maximum": 28396.11 } ] }, { "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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A0105", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B0105", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 3", "code_information": [ { "code": "D0105", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A0106", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B0106", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "C0106", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 3", "code_information": [ { "code": "D0106", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": 42026.16, "10th_percentile": 42026.16, "90th_percentile": 42026.16, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "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": 42026.16, "maximum": 42026.16 } ] }, { "description": "Traumatic brain injury M >=73.50- Tier None", "code_information": [ { "code": "A0201", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A0204", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B0204", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B0205", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 3", "code_information": [ { "code": "D0205", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A0301", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B0303", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A0304", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B0304", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "D0304", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A0305", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B0305", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "C0305", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": 34638.53, "10th_percentile": 34638.53, "90th_percentile": 34638.53, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "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": 34638.53, "maximum": 34638.53 } ] }, { "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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A0401", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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", 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schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A1403", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 2", "code_information": [ { "code": "C1403", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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- Tier None", "code_information": [ { "code": "A1404", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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- Tier Tier 1", "code_information": [ { "code": "B1404", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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- Tier Tier 2", "code_information": [ { "code": "C1404", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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- Tier Tier 3", "code_information": [ { "code": "D1404", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A1501", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B1502", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 3", "code_information": [ { "code": "D1503", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": 25939.71, "10th_percentile": 25939.71, "90th_percentile": 25939.71, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "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": 25939.71, "maximum": 25939.71 } ] }, { "description": "Pulmonary M <45.50- Tier None", "code_information": [ { "code": "A1504", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A1601", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B1702", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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"0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B1704", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A1705", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B1705", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": 37338.35, "10th_percentile": 37338.35, "90th_percentile": 37338.35, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "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": 37338.35, "maximum": 37338.35 } ] }, { "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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A1801", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 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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": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B1803", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B2002", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 2", "code_information": [ { "code": "C2002", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 None", "code_information": [ { "code": "A2003", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 1", "code_information": [ { "code": "B2003", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 2", "code_information": [ { "code": "C2003", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 A >=77.50- Tier None", "code_information": [ { "code": "A2004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 A >=77.50- Tier Tier 1", "code_information": [ { "code": "B2004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 A >=77.50- Tier Tier 2", "code_information": [ { "code": "C2004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 A >=77.50- Tier Tier 3", "code_information": [ { "code": "D2004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": 29063.68, "10th_percentile": 29063.68, "90th_percentile": 29063.68, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "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": 29063.68, "maximum": 29063.68 } ] }, { "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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 A <77.50- Tier Tier 1", "code_information": [ { "code": "B2005", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 A <77.50- Tier Tier 2", "code_information": [ { "code": "C2005", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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 A <77.50- Tier Tier 3", "code_information": [ { "code": "D2005", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": 30420.97, "10th_percentile": 30420.97, "90th_percentile": 30420.97, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "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": 30420.97, "maximum": 30420.97 } ] }, { "description": "Burns M >=52.50- Tier None", "code_information": [ { "code": "A2101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Room & Board - Semi-private (Two Beds) - Rehabilitation", "code_information": [ { "code": "0128", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 1200, "methodology": "per diem", "median_amount": 1200, "10th_percentile": 1200, "90th_percentile": 1200, "count": "1 through 10" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_dollar": 1600, "methodology": "per diem", "median_amount": 1600, "10th_percentile": 1600, "90th_percentile": 1600, "count": "1 through 10" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_dollar": 1600, "methodology": "per diem", "median_amount": 1600, "10th_percentile": 1600, "90th_percentile": 1600, "count": "1 through 10" }, { "payer_name": "Deseret Mutual Benefit Administrators", "plan_name": "Commercial: All Benefit Arrangements", "standard_charge_dollar": 1591, "methodology": "per diem", "median_amount": 1591, "10th_percentile": 1591, "90th_percentile": 1591, "count": "1 through 10" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "PPO", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 1200, "maximum": 1600 } ] }, { "description": "Room & Board - Three and Four Beds - Rehabilitation", "code_information": [ { "code": "0138", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 1200, "methodology": "per diem", "median_amount": 1200, "10th_percentile": 1200, "90th_percentile": 1200, "count": "1 through 10" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_dollar": 1600, "methodology": "per diem", "median_amount": 1600, "10th_percentile": 1600, "90th_percentile": 1600, "count": "1 through 10" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_dollar": 1600, "methodology": "per diem", "median_amount": 1600, "10th_percentile": 1600, "90th_percentile": 1600, "count": "1 through 10" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "PPO", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 1200, "maximum": 1600 } ] }, { "description": "Room & Board - Deluxe Private - Rehabilitation", "code_information": [ { "code": "0148", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 1200, "methodology": "per diem", "median_amount": 1200, "10th_percentile": 1200, "90th_percentile": 1200, "count": "1 through 10" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_dollar": 1600, "methodology": "per diem", "median_amount": 1600, "10th_percentile": 1600, "90th_percentile": 1600, "count": "1 through 10" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_dollar": 1600, "methodology": "per diem", "median_amount": 1600, "10th_percentile": 1600, "90th_percentile": 1600, "count": "1 through 10" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "PPO", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 1200, "maximum": 1600 } ] }, { "description": "Room & Board - Ward - Rehabilitation", "code_information": [ { "code": "0158", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 1200, "methodology": "per diem", "median_amount": 1200, "10th_percentile": 1200, "90th_percentile": 1200, "count": "1 through 10" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_dollar": 1600, "methodology": "per diem", "median_amount": 1600, "10th_percentile": 1600, "90th_percentile": 1600, "count": "1 through 10" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_dollar": 1600, "methodology": "per diem", "median_amount": 1600, "10th_percentile": 1600, "90th_percentile": 1600, "count": "1 through 10" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Health Choice Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "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": "Molina Healthcare of Utah", "plan_name": "Utah Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Individual & Family", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "FocalPoint", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Participating & Preferred", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "PPO", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "HealthWise", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Federal Employee Health Benefits Program (FEP)", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "ValueCare", "standard_charge_dollar": 1435, "methodology": "per diem", "median_amount": 1435, "10th_percentile": 1435, "90th_percentile": 1435, "count": "1 through 10" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "H.O.M.E. (Healthy Options Medical Excellence)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy U (Medicaid ACO Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 1200, "maximum": 1600 } ] }, { "description": "Inpatient Renal Dialysis - General Classification", "code_information": [ { "code": "0800", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 325, "methodology": "per diem", "median_amount": 325, "10th_percentile": 325, "90th_percentile": 325, "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" } ], "minimum": 325, "maximum": 325 } ] }, { "description": "Inpatient Renal Dialysis - Hemodialysis", "code_information": [ { "code": "0801", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 325, "methodology": "per diem", "median_amount": 325, "10th_percentile": 325, "90th_percentile": 325, "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": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_dollar": 550, "methodology": "fee schedule", "median_amount": 550, "10th_percentile": 550, "90th_percentile": 550, "count": "1 through 10" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_dollar": 550, "methodology": "fee schedule", "median_amount": 550, "10th_percentile": 550, "90th_percentile": 550, "count": "1 through 10" } ], "minimum": 325, "maximum": 550 } ] }, { "description": "Inpatient Renal Dialysis - Peritoneal Dialysis (Non-CAPD)", "code_information": [ { "code": "0802", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 325, "methodology": "per diem", "median_amount": 325, "10th_percentile": 325, "90th_percentile": 325, "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": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_dollar": 350, "methodology": "fee schedule", "median_amount": 350, "10th_percentile": 350, "90th_percentile": 350, "count": "1 through 10" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_dollar": 350, "methodology": "fee schedule", "median_amount": 350, "10th_percentile": 350, "90th_percentile": 350, "count": "1 through 10" } ], "minimum": 325, "maximum": 350 } ] }, { "description": "Inpatient Renal Dialysis - Continuous Ambulatory Peritoneal Dialysis (CAPD)", "code_information": [ { "code": "0803", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 325, "methodology": "per diem", "median_amount": 325, "10th_percentile": 325, "90th_percentile": 325, "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": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_dollar": 350, "methodology": "fee schedule", "median_amount": 350, "10th_percentile": 350, "90th_percentile": 350, "count": "1 through 10" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_dollar": 350, "methodology": "fee schedule", "median_amount": 350, "10th_percentile": 350, "90th_percentile": 350, "count": "1 through 10" } ], "minimum": 325, "maximum": 350 } ] }, { "description": "Inpatient Renal Dialysis - Continuous Cycling Peritoneal Dialysis (CCPD)", "code_information": [ { "code": "0804", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 325, "methodology": "per diem", "median_amount": 325, "10th_percentile": 325, "90th_percentile": 325, "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": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_dollar": 350, "methodology": "fee schedule", "median_amount": 350, "10th_percentile": 350, "90th_percentile": 350, "count": "1 through 10" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_dollar": 350, "methodology": "fee schedule", "median_amount": 350, "10th_percentile": 350, "90th_percentile": 350, "count": "1 through 10" } ], "minimum": 325, "maximum": 350 } ] }, { "description": "Inpatient Renal Dialysis - Other", "code_information": [ { "code": "0809", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 325, "methodology": "per diem", "median_amount": 325, "10th_percentile": 325, "90th_percentile": 325, "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" } ], "minimum": 325, "maximum": 325 } ] }, { "description": "Pharmacy - Drugs Requiring Detailed Coding", "code_information": [ { "code": "0636", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Preferred, Individual and Group (ACA)", "standard_charge_percentage": 110.00000000000001, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "University of Utah Health Plan (UUHP)", "plan_name": "Healthy Premier, Individual and Group (ACA)", "standard_charge_percentage": 110.00000000000001, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tib/per revasc w/ather", "code_information": [ { "code": "37229", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - Observation/Hourly", "code_information": [ { "code": "0417", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - Other", "code_information": [ { "code": "0418", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - Other", "code_information": [ { "code": "0419", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - General Classification", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Generic Drugs", "code_information": [ { "code": "0251", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Non-generic Drugs", "code_information": [ { "code": "0252", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Take Home Drugs", "code_information": [ { "code": "0253", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Drugs Incident To Other Diagnostic Services", "code_information": [ { "code": "0254", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Drugs Incident To Radiology", "code_information": [ { "code": "0255", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Experimental Drugs", "code_information": [ { "code": "0256", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Nonprescription", "code_information": [ { "code": "0257", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - IV Solutions", "code_information": [ { "code": "0258", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Other", "code_information": [ { "code": "0259", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy - General Classification", "code_information": [ { "code": "0260", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy - Infusion Pump", "code_information": [ { "code": "0261", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy/Pharmacy Services", "code_information": [ { "code": "0262", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy/Drug/Supply Delivery", "code_information": [ { "code": "0263", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy/Supplies", "code_information": [ { "code": "0264", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy - Treatment", "code_information": [ { "code": "0265", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy - Continuation", "code_information": [ { "code": "0266", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy - Observation/Hourly", "code_information": [ { "code": "0267", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy - Other", "code_information": [ { "code": "0268", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy - Other", "code_information": [ { "code": "0269", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Medical/Surgical Supplies and Devices - General Classification", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Immunology", "code_information": [ { "code": "0302", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Renal Patient (Home)", "code_information": [ { "code": "0303", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Non-routine Dialysis", "code_information": [ { "code": "0304", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Hematology", "code_information": [ { "code": "0305", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Bacteriology & Microbiology", "code_information": [ { "code": "0306", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Urology", "code_information": [ { "code": "0307", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Other", "code_information": [ { "code": "0308", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Other", "code_information": [ { "code": "0309", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory Pathology - General Classification", "code_information": [ { "code": "0310", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory Pathology - Cytology", "code_information": [ { "code": "0311", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory Pathology - Histology", "code_information": [ { "code": "0312", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory – Pathology - Assessment", "code_information": [ { "code": "0313", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory Pathology - Biopsy", "code_information": [ { "code": "0314", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory – Pathology - Treatment", "code_information": [ { "code": "0315", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory – Pathology - Continuation", "code_information": [ { "code": "0316", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory – Pathology - Observation/Hourly", "code_information": [ { "code": "0317", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - General Classification", "code_information": [ { "code": "0450", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - EMTALA Emergency Medical Screening Services", "code_information": [ { "code": "0451", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Beyond EMTALA Screening", "code_information": [ { "code": "0452", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Assessment", "code_information": [ { "code": "0453", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Evaluation or Testing", "code_information": [ { "code": "0454", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Treatment", "code_information": [ { "code": "0455", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Urgent Care", "code_information": [ { "code": "0456", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Observation/Hourly", "code_information": [ { "code": "0457", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Other", "code_information": [ { "code": "0458", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Other", "code_information": [ { "code": "0459", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - General Classification", "code_information": [ { "code": "0460", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Visit", "code_information": [ { "code": "0461", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Unit", "code_information": [ { "code": "0462", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Assessment", "code_information": [ { "code": "0463", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Evaluation or Testing", "code_information": [ { "code": "0464", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Treatment", "code_information": [ { "code": "0465", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Continuation", "code_information": [ { "code": "0466", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Observation/Hourly", "code_information": [ { "code": "0467", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Other", "code_information": [ { "code": "0468", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Other", "code_information": [ { "code": "0469", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Audiology - General Classification", "code_information": [ { "code": "0470", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Audiology - Diagnostic", "code_information": [ { "code": "0471", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Audiology - Treatment", "code_information": [ { "code": "0472", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ambulatory Surgical Care - Assessment", "code_information": [ { "code": "0473", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ambulatory Surgical Care - Evaluation or Testing", "code_information": [ { "code": "0474", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ambulatory Surgical Care - Treatment", "code_information": [ { "code": "0475", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ambulatory Surgical Care - Continuation", "code_information": [ { "code": "0476", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ambulatory Surgical Care - Observation/Hourly", "code_information": [ { "code": "0477", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ambulatory Surgical Care - Other", "code_information": [ { "code": "0478", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Audiology - Other", "code_information": [ { "code": "0479", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "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 PFFS", "standard_charge_percentage": 100, "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 HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Utah", "plan_name": "Medicare-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": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "Tricare Prime", "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 - General Classification", "code_information": [ { "code": "0820", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hemodialysis - Outpatient or Home - Hemodialysis Composite or Other Rate", "code_information": [ { "code": "0821", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hemodialysis - Outpatient or Home - Other OP Hemodialysis", "code_information": [ { "code": "0829", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Peritoneal Dialysis - Outpatient or Home - Peritoneal/Composite or Other Rate", "code_information": [ { "code": "0831", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "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": "Laboratory – Pathology - Other", "code_information": [ { "code": "0318", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory Pathology - Other", "code_information": [ { "code": "0319", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - General Classification", "code_information": [ { "code": "0320", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Angiocardiography", "code_information": [ { "code": "0321", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Arthrography", "code_information": [ { "code": "0322", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Arteriography", "code_information": [ { "code": "0323", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Chest X-Ray", "code_information": [ { "code": "0324", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Treatment", "code_information": [ { "code": "0325", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Continuation", "code_information": [ { "code": "0326", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Observation/Hourly", "code_information": [ { "code": "0327", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Other", "code_information": [ { "code": "0328", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Other", "code_information": [ { "code": "0329", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Therapeutic and/or Chemotherapy Administration - General Classification", "code_information": [ { "code": "0330", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Therapeutic - Chemotherapy Administration - Injected", "code_information": [ { "code": "0331", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Therapeutic - Chemotherapy Administration - Oral", "code_information": [ { "code": "0332", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Therapeutic - Radiation Therapy", "code_information": [ { "code": "0333", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology – Therapeutic - Evaluation or Testing", "code_information": [ { "code": "0334", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Therapeutic - Chemotherapy Administration - IV", "code_information": [ { "code": "0335", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology – Therapeutic - Continuation", "code_information": [ { "code": "0336", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology – Therapeutic - Observation/Hourly", "code_information": [ { "code": "0337", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology – Therapeutic - Other", "code_information": [ { "code": "0338", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Therapeutic - Other", "code_information": [ { "code": "0339", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - General Classification", "code_information": [ { "code": "0340", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Diagnostic Procedures", "code_information": [ { "code": "0341", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Therapeutic Procedures", "code_information": [ { "code": "0342", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Diagnostic Radiopharmaceuticals", "code_information": [ { "code": "0343", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Therapeutic Radiopharmaceuticals", "code_information": [ { "code": "0344", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Treatment", "code_information": [ { "code": "0345", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Continuation", "code_information": [ { "code": "0346", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Observation/Hourly", "code_information": [ { "code": "0347", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Other", "code_information": [ { "code": "0348", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Other", "code_information": [ { "code": "0349", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - General Classification", "code_information": [ { "code": "0350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Head Scan", "code_information": [ { "code": "0351", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Body Scan", "code_information": [ { "code": "0352", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Assessment", "code_information": [ { "code": "0353", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Evaluation or Testing", "code_information": [ { "code": "0354", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Treatment", "code_information": [ { "code": "0355", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Continuation", "code_information": [ { "code": "0356", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Observation/Hourly", "code_information": [ { "code": "0357", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Other", "code_information": [ { "code": "0358", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Other", "code_information": [ { "code": "0359", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - General Classification", "code_information": [ { "code": "0360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Minor Surgery", "code_information": [ { "code": "0361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Organ transplant - Other Than Kidney", "code_information": [ { "code": "0362", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Assessment", "code_information": [ { "code": "0363", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Evaluation or Testing", "code_information": [ { "code": "0364", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Treatment", "code_information": [ { "code": "0365", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Continuation", "code_information": [ { "code": "0366", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Kidney Transplant", "code_information": [ { "code": "0367", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Other", "code_information": [ { "code": "0368", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Other", "code_information": [ { "code": "0369", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - General Classification", "code_information": [ { "code": "0370", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Incident to Radiology", "code_information": [ { "code": "0371", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Incident to Other Diagnostic Services", "code_information": [ { "code": "0372", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Assessment", "code_information": [ { "code": "0373", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Acupuncture", "code_information": [ { "code": "0374", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Treatment", "code_information": [ { "code": "0375", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Continuation", "code_information": [ { "code": "0376", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Observation/Hourly", "code_information": [ { "code": "0377", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Other", "code_information": [ { "code": "0378", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Other", "code_information": [ { "code": "0379", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - General Classification", "code_information": [ { "code": "0400", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Diagnostic Mammography", "code_information": [ { "code": "0401", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Ultrasound", "code_information": [ { "code": "0402", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Screening Mammography", "code_information": [ { "code": "0403", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Positron Emission Tomography", "code_information": [ { "code": "0404", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Treatment", "code_information": [ { "code": "0405", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Continuation", "code_information": [ { "code": "0406", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Observation/Hourly", "code_information": [ { "code": "0407", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Other", "code_information": [ { "code": "0408", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Other", "code_information": [ { "code": "0409", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - Visit", "code_information": [ { "code": "0411", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - Inhalation Services", "code_information": [ { "code": "0412", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - Hyperbaric Oxygen Therapy", "code_information": [ { "code": "0413", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - Evaluation or Testing", "code_information": [ { "code": "0414", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - Treatment", "code_information": [ { "code": "0415", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - Continuation", "code_information": [ { "code": "0416", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Chorionic gonadotropin test", "code_information": [ { "code": "84702", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Chorionic gonadotropin assay", "code_information": [ { "code": "84703", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bl smear w/diff wbc count", "code_information": [ { "code": "85007", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bl smear w/o diff wbc count", "code_information": [ { "code": "85008", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hematocrit", "code_information": [ { "code": "85014", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hemoglobin", "code_information": [ { "code": "85018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Manual reticulocyte count", "code_information": [ { "code": "85044", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Automated platelet count", "code_information": [ { "code": "85049", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bone marrow interpretation", "code_information": [ { "code": "85097", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Coagulation time activated", "code_information": [ { "code": "85347", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fibrin degradation products", "code_information": [ { "code": "85362", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fibrin degradation quant", "code_information": [ { "code": "85379", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fibrinogen activity", "code_information": [ { "code": "85384", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Blood platelet aggregation", "code_information": [ { "code": "85576", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rbc sed rate nonautomated", "code_information": [ { "code": "85651", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Thromboplastin time partial", "code_information": [ { "code": "85730", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Platelet antibodies", "code_information": [ { "code": "86022", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Antinuclear antibodies", "code_information": [ { "code": "86038", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dna antibody native", "code_information": [ { "code": "86225", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear antigen antibody", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fluorescent antibody titer", "code_information": [ { "code": "86256", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Immunoassay tumor ca 15-3", "code_information": [ { "code": "86300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Immunoassay tumor ca 19-9", "code_information": [ { "code": "86301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Immunoassay tumor ca 125", "code_information": [ { "code": "86304", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rheumatoid factor quant", "code_information": [ { "code": "86431", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tb test cell immun measure", "code_information": [ { "code": "86480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Syphilis test non-trep qual", "code_information": [ { "code": "86592", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Herpes simplex nes antbdy", "code_information": [ { "code": "86694", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Herpes simplex type 1 test", "code_information": [ { "code": "86695", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Herpes simplex type 2 test", "code_information": [ { "code": "86696", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hep b core antibody igm", "code_information": [ { "code": "86705", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hep b surface antibody", "code_information": [ { "code": "86706", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lymph choriomeningitis ab", "code_information": [ { "code": "86727", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mumps antibody", "code_information": [ { "code": "86735", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rubeola antibody", "code_information": [ { "code": "86765", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treponema pallidum", "code_information": [ { "code": "86780", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Varicella-zoster antibody", "code_information": [ { "code": "86787", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rbc antibody screen", "code_information": [ { "code": "86850", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rbc antibody identification", "code_information": [ { "code": "86870", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Coombs test direct", "code_information": [ { "code": "86880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Blood typing serologic abo", "code_information": [ { "code": "86900", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Blood typing serologic rh(d)", "code_information": [ { "code": "86901", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bld typing serologic rh phnt", "code_information": [ { "code": "86906", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Compatibility test spin", "code_information": [ { "code": "86920", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Compatibility test antiglob", "code_information": [ { "code": "86922", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Unlisted transfusion med px", "code_information": [ { "code": "86999", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Feces culture aerobic bact", "code_information": [ { "code": "87045", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stool cultr aerobic bact ea", "code_information": [ { "code": "87046", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cultr bacteria except blood", "code_information": [ { "code": "87075", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Culture anaerobe ident each", "code_information": [ { "code": "87076", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Culture aerobic identify", "code_information": [ { "code": "87077", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Urine bacteria culture", "code_information": [ { "code": "87088", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Skin fungi culture", "code_information": [ { "code": "87101", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fungi identification yeast", "code_information": [ { "code": "87106", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mycobacteria culture", "code_information": [ { "code": "87116", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Culture type immunologic", "code_information": [ { "code": "87147", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dna/rna amplified probe", "code_information": [ { "code": "87150", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Microbe susceptible diffuse", "code_information": [ { "code": "87181", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Microbe susceptible disk", "code_information": [ { "code": "87184", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Microbe susceptible mic", "code_information": [ { "code": "87186", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Smear gram stain", "code_information": [ { "code": "87205", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Smear wet mount saline/ink", "code_information": [ { "code": "87210", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Aspergillus ag ia", "code_information": [ { "code": "87305", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clostridium ag ia", "code_information": [ { "code": "87324", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cryptococcus neoform ag ia", "code_information": [ { "code": "87327", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Resp syncytial virus ag ia", "code_information": [ { "code": "87420", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sarscov coronavirus ag ia", "code_information": [ { "code": "87426", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Shiga-like toxin ag ia", "code_information": [ { "code": "87427", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nos each organism ag ia", "code_information": [ { "code": "87449", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Chlmyd trach dna dir probe", "code_information": [ { "code": "87490", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Chlmyd trach dna amp probe", "code_information": [ { "code": "87491", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Influenza dna amp probe", "code_information": [ { "code": "87502", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hepatitis c revrs trnscrpj", "code_information": [ { "code": "87522", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hsv dna amp probe", "code_information": [ { "code": "87529", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hiv-1 quant&revrse trnscrpj", "code_information": [ { "code": "87536", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "M.tuberculo dna amp probe", "code_information": [ { "code": "87556", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "N.gonorrhoeae dna amp prob", "code_information": [ { "code": "87591", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - General Classification", "code_information": [ { "code": "0480", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Cardiac Cath Lab", "code_information": [ { "code": "0481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Stress Test", "code_information": [ { "code": "0482", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Echocardiology", "code_information": [ { "code": "0483", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Evaluation or Testing", "code_information": [ { "code": "0484", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Treatment", "code_information": [ { "code": "0485", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Continuation", "code_information": [ { "code": "0486", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Observation/Hourly", "code_information": [ { "code": "0487", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Other", "code_information": [ { "code": "0488", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Other", "code_information": [ { "code": "0489", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ambulatory Surgical Care - General Classification", "code_information": [ { "code": "0490", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - General Classification", "code_information": [ { "code": "0510", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Chronic Pain Center", "code_information": [ { "code": "0511", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Dental", "code_information": [ { "code": "0512", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Psychiatric", "code_information": [ { "code": "0513", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - OB-GYN", "code_information": [ { "code": "0514", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Pediatric", "code_information": [ { "code": "0515", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Urgent Care", "code_information": [ { "code": "0516", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Family Practice", "code_information": [ { "code": "0517", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Other", "code_information": [ { "code": "0518", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Other", "code_information": [ { "code": "0519", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - General Classification", "code_information": [ { "code": "0520", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Clinic visit by member to RHC/FQHC", "code_information": [ { "code": "0521", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Home visit by RHC/FQHC practitioner", "code_information": [ { "code": "0522", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Family Practice", "code_information": [ { "code": "0523", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Visit by RHC/FQHC practitioner to a member in a SNF or Skilled Swing Bed in a covered Part A stay", "code_information": [ { "code": "0524", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Visit by RHC/FQHC practitioner to a member in a SNF (not in a covered Part A stay) or NF or ICF MR or other residential facility", "code_information": [ { "code": "0525", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Urgent Care", "code_information": [ { "code": "0526", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - RHC/FQHC Visiting Nurse Service(s) to a member's home when in a home health shortage area", "code_information": [ { "code": "0527", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Visit by RHC/FQHC practitioner to other non RHC/FQHC site (e.g., scene of accident)", "code_information": [ { "code": "0528", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Other", "code_information": [ { "code": "0529", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Magnetic Resonance Technology (MRT) - General Classification", "code_information": [ { "code": "0610", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG (Electrocardiogram) - General Classification", "code_information": [ { "code": "0730", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG (Electrocardiogram) - Holter Monitor", "code_information": [ { "code": "0731", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG (Electrocardiogram) - Telemetry", "code_information": [ { "code": "0732", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG - Assessment", "code_information": [ { "code": "0733", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG - Evaluation or Testing", "code_information": [ { "code": "0734", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG - Treatment", "code_information": [ { "code": "0735", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG - Continuation", "code_information": [ { "code": "0736", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG - Observation/Hourly", "code_information": [ { "code": "0737", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG - Other", "code_information": [ { "code": "0738", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG (Electrocardiogram) - Other", "code_information": [ { "code": "0739", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG (Electroencephalogram) - General Classification", "code_information": [ { "code": "0740", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Visit", "code_information": [ { "code": "0741", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Unit", "code_information": [ { "code": "0742", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Assessment", "code_information": [ { "code": "0743", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Evaluation or Testing", "code_information": [ { "code": "0744", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Treatment", "code_information": [ { "code": "0745", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Continuation", "code_information": [ { "code": "0746", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Observation/Hourly", "code_information": [ { "code": "0747", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Other", "code_information": [ { "code": "0748", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Other", "code_information": [ { "code": "0749", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Psychiatric/psychological services-general classification", "code_information": [ { "code": "0910", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Rehabilitation", "code_information": [ { "code": "0911", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Partial Hospitalization - Less Intensive", "code_information": [ { "code": "0912", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Partial Hospitalization - Intensive", "code_information": [ { "code": "0913", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Individual Therapy", "code_information": [ { "code": "0914", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Group Therapy", "code_information": [ { "code": "0915", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Family Therapy", "code_information": [ { "code": "0916", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Bio Feedback", "code_information": [ { "code": "0917", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Testing", "code_information": [ { "code": "0918", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Other", "code_information": [ { "code": "0919", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - General Classification", "code_information": [ { "code": "0920", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Peripheral Vascular Lab", "code_information": [ { "code": "0921", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Electromyogram", "code_information": [ { "code": "0922", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Pap Smear", "code_information": [ { "code": "0923", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Allergy Test", "code_information": [ { "code": "0924", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Pregnancy Test", "code_information": [ { "code": "0925", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Continuation", "code_information": [ { "code": "0926", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Observation/Hourly", "code_information": [ { "code": "0927", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Other", "code_information": [ { "code": "0928", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Other Diagnostic Service", "code_information": [ { "code": "0929", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - General Classification", "code_information": [ { "code": "0930", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Medical Rehabilitation Day Program - Half Day", "code_information": [ { "code": "0931", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_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": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - Assessment", "code_information": [ { "code": "0933", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - Evaluation or Testing", "code_information": [ { "code": "0934", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - Treatment", "code_information": [ { "code": "0935", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - Continuation", "code_information": [ { "code": "0936", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - Observation/Hourly", "code_information": [ { "code": "0937", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - Other", "code_information": [ { "code": "0938", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - Other", "code_information": [ { "code": "0939", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - General Classification", "code_information": [ { "code": "0940", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Recreational Therapy", "code_information": [ { "code": "0941", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Education/Training", "code_information": [ { "code": "0942", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Cardiac Rehabilitation", "code_information": [ { "code": "0943", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Drug Rehabilitation", "code_information": [ { "code": "0944", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Alcohol Rehabilitation", "code_information": [ { "code": "0945", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Complex Medical Equipment - Routine", "code_information": [ { "code": "0946", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Complex Medical Equipment - Ancillary", "code_information": [ { "code": "0947", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Pulmonary Rehabilitation", "code_information": [ { "code": "0948", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Other", "code_information": [ { "code": "0949", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth ear surgery", "code_information": [ { "code": "00120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth head/neck/ptrunk", "code_information": [ { "code": "00300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Strep a dna dir probe", "code_information": [ { "code": "87650", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Strep a dna amp probe", "code_information": [ { "code": "87651", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Influenza assay w/optic", "code_information": [ { "code": "87804", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hiv ag w/hiv1&2 antb w/optic", "code_information": [ { "code": "87806", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sars-cov-2 covid19 w/optic", "code_information": [ { "code": "87811", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Strep a assay w/optic", "code_information": [ { "code": "87880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cytopath concentrate tech", "code_information": [ { "code": "88108", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cytopath cell enhance tech", "code_information": [ { "code": "88112", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cytopath smear other source", "code_information": [ { "code": "88161", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cytopath eval fna report", "code_information": [ { "code": "88173", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Surgical path gross", "code_information": [ { "code": "88300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tissue exam by pathologist", "code_information": [ { "code": "88302", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tissue exam by pathologist", "code_information": [ { "code": "88304", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tissue exam by pathologist", "code_information": [ { "code": "88305", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tissue exam by pathologist", "code_information": [ { "code": "88307", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tissue exam by pathologist", "code_information": [ { "code": "88309", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Decalcify tissue", "code_information": [ { "code": "88311", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Special stains group 1", "code_information": [ { "code": "88312", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Special stains group 2", "code_information": [ { "code": "88313", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Path consltj drg surg", "code_information": [ { "code": "88329", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Path consltj surg 1 blk 1spc", "code_information": [ { "code": "88331", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Imhchem/imcytchm ea add antb", "code_information": [ { "code": "88341", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Imhchem/imcytchm 1st antb", "code_information": [ { "code": "88342", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Body fluid cell count", "code_information": [ { "code": "89050", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Body fluid cell count", "code_information": [ { "code": "89051", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Immunization admin", "code_information": [ { "code": "90471", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rabies vaccine im", "code_information": [ { "code": "90675", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tdap vaccine 7 yrs/> im", "code_information": [ { "code": "90715", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Group psychotherapy", "code_information": [ { "code": "90853", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Extended visual field xm", "code_information": [ { "code": "92083", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cmptr ophth img optic nerve", "code_information": [ { "code": "92133", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cptr ophth dx img post segmt", "code_information": [ { "code": "92134", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fundus photography w/i&r", "code_information": [ { "code": "92250", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Motion fluoroscopy/swallow", "code_information": [ { "code": "92611", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Aep neurodiagnostic i&r", "code_information": [ { "code": "92653", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prq card stent w/angio 1 vsl", "code_information": [ { "code": "92928", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prq card stent w/angio addl", "code_information": [ { "code": "92929", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prq revasc byp graft 1 vsl", "code_information": [ { "code": "92937", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Heart/lung resuscitation cpr", "code_information": [ { "code": "92950", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardioversion electric ext", "code_information": [ { "code": "92960", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Endoluminl ivus oct c 1st", "code_information": [ { "code": "92978", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Electrocardiogram tracing", "code_information": [ { "code": "93005", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiovascular stress test", "code_information": [ { "code": "93017", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ecg monit/reprt up to 48 hrs", "code_information": [ { "code": "93225", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ecg monit/reprt up to 48 hrs", "code_information": [ { "code": "93226", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tte w/doppler complete", "code_information": [ { "code": "93306", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tte f-up or lmtd", "code_information": [ { "code": "93308", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Echo transesophageal", "code_information": [ { "code": "93312", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Coronary artery angio s&i", "code_information": [ { "code": "93454", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "L hrt artery/ventricle angio", "code_information": [ { "code": "93458", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "L hrt art/grft angio", "code_information": [ { "code": "93459", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "R&l hrt art/ventricle angio", "code_information": [ { "code": "93460", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Heart flow reserve measure", "code_information": [ { "code": "93571", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Heart flow reserve measure", "code_information": [ { "code": "93572", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac rehab/monitor", "code_information": [ { "code": "93798", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Extracranial bilat study", "code_information": [ { "code": "93880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lower extremity study", "code_information": [ { "code": "93925", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Upper extremity study", "code_information": [ { "code": "93930", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dup-scan hemo compl bi std", "code_information": [ { "code": "93985", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Doppler flow testing", "code_information": [ { "code": "93990", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Evaluation of wheezing", "code_information": [ { "code": "94060", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Airway inhalation treatment", "code_information": [ { "code": "94640", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pos airway pressure cpap", "code_information": [ { "code": "94660", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Measure blood oxygen level", "code_information": [ { "code": "94760", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Measure blood oxygen level", "code_information": [ { "code": "94761", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Unlisted pulmonary svc/px", "code_information": [ { "code": "94799", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Eeg awake and drowsy", "code_information": [ { "code": "95816", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Eeg awake and asleep", "code_information": [ { "code": "95819", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Musc test done w/n test comp", "code_information": [ { "code": "95886", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nrv cndj test 13/> studies", "code_information": [ { "code": "95913", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hydration iv infusion init", "code_information": [ { "code": "96360", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hydrate iv infusion add-on", "code_information": [ { "code": "96361", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ther/proph/diag iv inf init", "code_information": [ { "code": "96365", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ther/proph/diag iv inf addon", "code_information": [ { "code": "96366", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tx/proph/dg addl seq iv inf", "code_information": [ { "code": "96367", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ther/diag concurrent inf", "code_information": [ { "code": "96368", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ther/proph/diag inj sc/im", "code_information": [ { "code": "96372", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ther/proph/diag inj iv push", "code_information": [ { "code": "96374", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tx/pro/dx inj new drug addon", "code_information": [ { "code": "96375", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tx/pro/dx inj same drug adon", "code_information": [ { "code": "96376", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mod sed same phys/qhp 5/>yrs", "code_information": [ { "code": "99152", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mod sed same phys/qhp ea", "code_information": [ { "code": "99153", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mod sed other phys/qhp ea", "code_information": [ { "code": "99157", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emr dpt vst mayx req phy/qhp", "code_information": [ { "code": "99281", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency dept visit sf mdm", "code_information": [ { "code": "99282", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency dept visit low mdm", "code_information": [ { "code": "99283", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency dept visit mod mdm", "code_information": [ { "code": "99284", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency dept visit hi mdm", "code_information": [ { "code": "99285", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Critical care first hour", "code_information": [ { "code": "99291", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sterile water/saline, 10 ml", "code_information": [ { "code": "A4216", "type": "HCPCS" }, { "code": "00019-1188-75", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 50, "type": "ML" } }, { "description": "Sterile water/saline, 500 ml", "code_information": [ { "code": "A4217", "type": "HCPCS" }, { "code": "00019-1188-27", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 125, "type": "ML" } }, { "description": "Fem urinary collect pouch", "code_information": [ { "code": "A4328", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bedside drainage bag", "code_information": [ { "code": "A4357", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Implantable tissue marker", "code_information": [ { "code": "A4648", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Surgical supplies", "code_information": [ { "code": "A4649", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clsd ostomy pouch w/flange", "code_information": [ { "code": "A5054", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Foam drg <=16 sq in w/border", "code_information": [ { "code": "A6212", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sterile gauze>16 <= 48 sq in", "code_information": [ { "code": "A6403", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tc99m medronate", "code_information": [ { "code": "A9503", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "I131 iodide cap, rx", "code_information": [ { "code": "A9517", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tc99m mebrofenin", "code_information": [ { "code": "A9537", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tc99m succimer", "code_information": [ { "code": "A9551", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Gad-base mr contrast nos,1ml", "code_information": [ { "code": "A9579", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, transluminal atherectomy, directional", "code_information": [ { "code": "C1714", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, transluminal angioplasty, non-laser (may include guidance, infusion/perfusion capability)", "code_information": [ { "code": "C1725", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, balloon dilatation, non-vascular", "code_information": [ { "code": "C1726", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, drainage", "code_information": [ { "code": "C1729", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, electrophysiology, diagnostic, other than 3d mapping (19 or fewer electrodes)", "code_information": [ { "code": "C1730", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Endoscope, single-use (i.e. disposable), urinary tract, imaging/illumination device (insertable)", "code_information": [ { "code": "C1747", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, hemodialysis/peritoneal, long-term", "code_information": [ { "code": "C1750", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, infusion, inserted peripherally, centrally or midline (other than hemodialysis)", "code_information": [ { "code": "C1751", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, intravascular ultrasound", "code_information": [ { "code": "C1753", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, thrombectomy/embolectomy", "code_information": [ { "code": "C1757", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, ureteral", "code_information": [ { "code": "C1758", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Closure device, vascular (implantable/insertable)", "code_information": [ { "code": "C1760", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, transluminal intravascular lithotripsy, coronary", "code_information": [ { "code": "C1761", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Connective tissue, human (includes fascia lata)", "code_information": [ { "code": "C1762", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Connective tissue, non-human (includes synthetic)", "code_information": [ { "code": "C1763", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Introducer/sheath, guiding, intracardiac electrophysiological, steerable, other than peel-away", "code_information": [ { "code": "C1766", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Graft, vascular", "code_information": [ { "code": "C1768", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Guide wire", "code_information": [ { "code": "C1769", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Repair device, urinary, incontinence, with sling graft", "code_information": [ { "code": "C1771", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Joint device (implantable)", "code_information": [ { "code": "C1776", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lens, intraocular (new technology)", "code_information": [ { "code": "C1780", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mesh (implantable)", "code_information": [ { "code": "C1781", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "OCULAR IMP, AQUEOUS DRAIN DE", "code_information": [ { "code": "C1783", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pacemaker, dual chamber, rate-responsive (implantable)", "code_information": [ { "code": "C1785", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Port, indwelling (implantable)", "code_information": [ { "code": "C1788", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prosthesis, urinary sphincter (implantable)", "code_information": [ { "code": "C1815", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Surgical tissue localization and excision device (implantable)", "code_information": [ { "code": "C1819", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Powered bone marrow biopsy needle", "code_information": [ { "code": "C1830", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stent, coated/covered, with delivery system", "code_information": [ { "code": "C1874", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stent, non-coated/non-covered, with delivery system", "code_information": [ { "code": "C1876", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardioverter-defibrillator, other than single or dual chamber (implantable)", "code_information": [ { "code": "C1882", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Embolization protective system", "code_information": [ { "code": "C1884", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, guiding (may include infusion/perfusion capability)", "code_information": [ { "code": "C1887", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Implantable/insertable device, not otherwise classified", "code_information": [ { "code": "C1889", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Introducer/sheath, other than guiding, other than intracardiac electrophysiological, non-laser", "code_information": [ { "code": "C1894", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lead, pacemaker, other than transvenous vdd single pass", "code_information": [ { "code": "C1898", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stent, non-coronary, temporary, without delivery system", "code_information": [ { "code": "C2617", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, transluminal angioplasty, drug-coated, non-laser", "code_information": [ { "code": "C2623", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "PROTONIX IV 40 MG", "code_information": [ { "code": "C9113", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "INJ, BUPIVACAINE LIPOSOME", "code_information": [ { "code": "C9290", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty within the same vessel(s), when performed", "code_information": [ { "code": "C9765", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intraoperative near-infrared fluorescence imaging of major extra-hepatic bile duct(s) (e.g., cystic duct, common bile duct and common hepatic duct) with intravenous administration of indocyanine green (icg) (list separately in addition to code for primary procedure)", "code_information": [ { "code": "C9776", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source", "code_information": [ { "code": "C9803", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Caries risk assess high risk", "code_information": [ { "code": "D0603", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Antigen test pub hlth pathog", "code_information": [ { "code": "D0604", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "2d oral/facial photo image", "code_information": [ { "code": "D0703", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Admin influenza virus vac", "code_information": [ { "code": "G0008", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Unsched dialysis esrd pt hos", "code_information": [ { "code": "G0257", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hospital observation per hr", "code_information": [ { "code": "G0378", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Direct refer hospital observ", "code_information": [ { "code": "G0379", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Trauma respons w/hosp criti", "code_information": [ { "code": "G0390", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hospital outpt clinic visit", "code_information": [ { "code": "G0463", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Drug test def 1-7 classes", "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, acetaminophen (nos)", "code_information": [ { "code": "J0131", "type": "HCPCS" }, { "code": "36000-0372-40", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 65, "type": "ML" } }, { "description": "Adrenalin epinephrine inject", "code_information": [ { "code": "J0171", "type": "HCPCS" }, { "code": "00093-5985-27", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2, "type": "EA" } }, { "description": "Ampicillin 500 mg inj", "code_information": [ { "code": "J0290", "type": "HCPCS" }, { "code": "00409-3718-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "EA" } }, { "description": "Ampicillin sulbactam 1.5 gm", "code_information": [ { "code": "J0295", "type": "HCPCS" }, { "code": "00049-0013-83", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Succinycholine chloride inj", "code_information": [ { "code": "J0330", "type": "HCPCS" }, { "code": "00143-9338-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "ML" } }, { "description": "Hydralazine hcl injection", "code_information": [ { "code": "J0360", "type": "HCPCS" }, { "code": "00641-6231-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Azithromycin", "code_information": [ { "code": "J0456", "type": "HCPCS" }, { "code": "00069-3150-83", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Atropine sulfate injection", "code_information": [ { "code": "J0461", "type": "HCPCS" }, { "code": "16729-0512-43", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 20, "type": "ML" } }, { "description": "Dicyclomine injection", "code_information": [ { "code": "J0500", "type": "HCPCS" }, { "code": "00517-1980-05", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2, "type": "ML" } }, { "description": "Bivalirudin", "code_information": [ { "code": "J0583", "type": "HCPCS" }, { "code": "00338-9572-24", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 50, "type": "ML" } }, { "description": "Calcium glucon (fresenius)", "code_information": [ { "code": "J0612", "type": "HCPCS" }, { "code": "00143-9180-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "ML" } }, { "description": "Inj, bupivacaine, nos, 0.5mg", "code_information": [ { "code": "J0665", "type": "HCPCS" }, { "code": "00143-9328-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 50, "type": "ML" } }, { "description": "Cefazolin sodium injection", "code_information": [ { "code": "J0690", "type": "HCPCS" }, { "code": "00143-9261-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "EA" } }, { "description": "Cefepime hcl for injection", "code_information": [ { "code": "J0692", "type": "HCPCS" }, { "code": "00409-9566-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "EA" } }, { "description": "Cefoxitin sodium injection", "code_information": [ { "code": "J0694", "type": "HCPCS" }, { "code": "00264-3123-11", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Ceftriaxone sodium injection", "code_information": [ { "code": "J0696", "type": "HCPCS" }, { "code": "00143-9678-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Ceftaroline fosamil inj", "code_information": [ { "code": "J0712", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj ceftazidime per 500 mg", "code_information": [ { "code": "J0713", "type": "HCPCS" }, { "code": "00409-5082-16", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Ciprofloxacin iv", "code_information": [ { "code": "J0744", "type": "HCPCS" }, { "code": "00409-2300-24", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 100, "type": "ML" } }, { "description": "Dexamethasone sodium phos", "code_information": [ { "code": "J1100", "type": "HCPCS" }, { "code": "00641-0367-21", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Hydromorphone injection", "code_information": [ { "code": "J1170", "type": "HCPCS" }, { "code": "00409-1283-05", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 0.5, "type": "ML" } }, { "description": "Injection, hydromorphone, 0.1 mg", "code_information": [ { "code": "J1171", "type": "HCPCS" }, { "code": "00409-1283-31", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Inj tbo filgrastim 1 microg", "code_information": [ { "code": "J1447", "type": "HCPCS" }, { "code": "63459-0918-59", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Fluconazole", "code_information": [ { "code": "J1450", "type": "HCPCS" }, { "code": "00338-6045-37", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 200, "type": "ML" } }, { "description": "Garamycin gentamicin inj", "code_information": [ { "code": "J1580", "type": "HCPCS" }, { "code": "00143-9128-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2, "type": "ML" } }, { "description": "Glucagon hydrochloride/1 mg", "code_information": [ { "code": "J1610", "type": "HCPCS" }, { "code": "00002-8031-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Haloperidol injection", "code_information": [ { "code": "J1630", "type": "HCPCS" }, { "code": "00143-9319-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Inj heparin sodium per 1000u", "code_information": [ { "code": "J1644", "type": "HCPCS" }, { "code": "00264-5705-05", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 0.5, "type": "ML" } }, { "description": "Insulin injection", "code_information": [ { "code": "J1815", "type": "HCPCS" }, { "code": "00002-7511-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "ML" } }, { "description": "Ketorolac tromethamine inj", "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "00338-0069-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Furosemide injection", "code_information": [ { "code": "J1940", "type": "HCPCS" }, { "code": "00143-9155-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2, "type": "ML" } }, { "description": "Levetiracetam injection", "code_information": [ { "code": "J1953", "type": "HCPCS" }, { "code": "00143-9673-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 5, "type": "ML" } }, { "description": "Levofloxacin injection", "code_information": [ { "code": "J1956", "type": "HCPCS" }, { "code": "00143-9315-24", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 50, "type": "ML" } }, { "description": "Lidocaine injection", "code_information": [ { "code": "J2001", "type": "HCPCS" }, { "code": "00264-9594-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 500, "type": "ML" } }, { "description": "Injection, lidocaine hydrochloride, 1 mg", "code_information": [ { "code": "J2003", "type": "HCPCS" }, { "code": "00143-9172-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 20, "type": "ML" } }, { "description": "Linezolid injection", "code_information": [ { "code": "J2020", "type": "HCPCS" }, { "code": "00009-5137-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 100, "type": "ML" } }, { "description": "Lorazepam injection", "code_information": [ { "code": "J2060", "type": "HCPCS" }, { "code": "00409-1539-31", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Meperidine hydrochl /100 mg", "code_information": [ { "code": "J2175", "type": "HCPCS" }, { "code": "00338-2691-75", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 50, "type": "ML" } }, { "description": "Meropenem", "code_information": [ { "code": "J2185", "type": "HCPCS" }, { "code": "00069-0313-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "EA" } }, { "description": "Inj midazolam hydrochloride", "code_information": [ { "code": "J2250", "type": "HCPCS" }, { "code": "00409-0001-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2, "type": "ML" } }, { "description": "Morphine sulfate injection", "code_information": [ { "code": "J2270", "type": "HCPCS" }, { "code": "00406-1521-53", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 5, "type": "GM" } }, { "description": "Inj naloxone hydrochloride", "code_information": [ { "code": "J2310", "type": "HCPCS" }, { "code": "00409-1215-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Octreotide inj, non-depot", "code_information": [ { "code": "J2354", "type": "HCPCS" }, { "code": "00078-0180-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Inj phenylephrine hcl 20 mcg", "code_information": [ { "code": "J2371", "type": "HCPCS" }, { "code": "00641-6188-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 5, "type": "ML" } }, { "description": "Ondansetron hcl injection", "code_information": [ { "code": "J2405", "type": "HCPCS" }, { "code": "00143-9890-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 20, "type": "ML" } }, { "description": "Papaverin hcl injection", "code_information": [ { "code": "J2440", "type": "HCPCS" }, { "code": "00517-4002-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2, "type": "ML" } }, { "description": "Injection, pantoprazole sodium, 40 mg", "code_information": [ { "code": "J2470", "type": "HCPCS" }, { "code": "00143-9300-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "EA" } }, { "description": "Piperacillin/tazobactam", "code_information": [ { "code": "J2543", "type": "HCPCS" }, { "code": "00206-8852-16", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Phenobarbital sodium inj", "code_information": [ { "code": "J2560", "type": "HCPCS" }, { "code": "00641-0476-21", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Inj, vasopressin, 1 unit", "code_information": [ { "code": "J2598", "type": "HCPCS" }, { "code": "00548-9701-00", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Inj, propofol, 10 mg", "code_information": [ { "code": "J2704", "type": "HCPCS" }, { "code": "00069-0209-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 20, "type": "ML" } }, { "description": "Neostigmine methylslfte inj", "code_information": [ { "code": "J2710", "type": "HCPCS" }, { "code": "00517-1133-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "ML" } }, { "description": "Inj protamine sulfate/10 mg", "code_information": [ { "code": "J2720", "type": "HCPCS" }, { "code": "49452-6109-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 5, "type": "GM" } }, { "description": "Metoclopramide hcl injection", "code_information": [ { "code": "J2765", "type": "HCPCS" }, { "code": "00409-3414-11", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2, "type": "ML" } }, { "description": "Regadenoson injection", "code_information": [ { "code": "J2785", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rho d immune globulin inj", "code_information": [ { "code": "J2790", "type": "HCPCS" }, { "code": "00562-7805-00", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Ropivacaine hcl injection", "code_information": [ { "code": "J2795", "type": "HCPCS" }, { "code": "00143-9263-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 20, "type": "ML" } }, { "description": "Na ferric gluconate complex", "code_information": [ { "code": "J2916", "type": "HCPCS" }, { "code": "00143-9298-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 5, "type": "ML" } }, { "description": "Injection, methylprednisolone sodium succinate, 5 mg", "code_information": [ { "code": "J2919", "type": "HCPCS" }, { "code": "00009-0039-06", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 25, "type": "EA" } }, { "description": "Methylprednisolone injection", "code_information": [ { "code": "J2920", "type": "HCPCS" }, { "code": "00143-9753-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 25, "type": "EA" } }, { "description": "Methylprednisolone injection", "code_information": [ { "code": "J2930", "type": "HCPCS" }, { "code": "00009-0698-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Fentanyl citrate injection", "code_information": [ { "code": "J3010", "type": "HCPCS" }, { "code": "00406-1130-52", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Terbutaline sulfate inj", "code_information": [ { "code": "J3105", "type": "HCPCS" }, { "code": "00143-9375-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Diazepam injection", "code_information": [ { "code": "J3360", "type": "HCPCS" }, { "code": "00409-1273-32", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2, "type": "ML" } }, { "description": "Vancomycin hcl injection", "code_information": [ { "code": "J3370", "type": "HCPCS" }, { "code": "00143-9161-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 25, "type": "EA" } }, { "description": "Hyaluronidase injection", "code_information": [ { "code": "J3470", "type": "HCPCS" }, { "code": "00548-9090-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "EA" } }, { "description": "Hyaluronidase recombinant", "code_information": [ { "code": "J3473", "type": "HCPCS" }, { "code": "18657-0117-04", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Inj magnesium sulfate", "code_information": [ { "code": "J3475", "type": "HCPCS" }, { "code": "00264-4204-52", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 50, "type": "ML" } }, { "description": "Inj potassium chloride", "code_information": [ { "code": "J3480", "type": "HCPCS" }, { "code": "00264-1940-20", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 250, "type": "ML" } }, { "description": "Drugs unclassified injection", "code_information": [ { "code": "J3490", "type": "HCPCS" }, { "code": "00004-0350-09", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Normal saline solution infus", "code_information": [ { "code": "J7030", "type": "HCPCS" }, { "code": "00264-7800-00", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1000, "type": "ML" } }, { "description": "Normal saline solution infus", "code_information": [ { "code": "J7040", "type": "HCPCS" }, { "code": "00264-5802-00", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1000, "type": "ML" } }, { "description": "5% dextrose/normal saline", "code_information": [ { "code": "J7042", "type": "HCPCS" }, { "code": "00264-7610-00", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1000, "type": "ML" } }, { "description": "Normal saline solution infus", "code_information": [ { "code": "J7050", "type": "HCPCS" }, { "code": "00264-1800-32", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 100, "type": "ML" } }, { "description": "5% dextrose/water", "code_information": [ { "code": "J7060", "type": "HCPCS" }, { "code": "00264-1510-31", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 50, "type": "ML" } }, { "description": "Ringers lactate infusion", "code_information": [ { "code": "J7120", "type": "HCPCS" }, { "code": "00264-7750-00", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1000, "type": "ML" } }, { "description": "Tacrolimus imme rel oral 1mg", "code_information": [ { "code": "J7507", "type": "HCPCS" }, { "code": "00378-2045-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 100, "type": "EA" } }, { "description": "Prednisolone oral per 5 mg", "code_information": [ { "code": "J7510", "type": "HCPCS" }, { "code": "00093-6118-87", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 240, "type": "ML" } }, { "description": "Prednisone ir or dr oral 1mg", "code_information": [ { "code": "J7512", "type": "HCPCS" }, { "code": "00054-0017-20", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 100, "type": "EA" } }, { "description": "Mycophenolate mofetil oral", "code_information": [ { "code": "J7517", "type": "HCPCS" }, { "code": "00004-0259-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 100, "type": "EA" } }, { "description": "Non-inhalation drug for dme", "code_information": [ { "code": "J7799", "type": "HCPCS" }, { "code": "00264-2303-50", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2000, "type": "ML" } }, { "description": "Oral prescrip drug non chemo", "code_information": [ { "code": "J8499", "type": "HCPCS" }, { "code": "00004-0038-22", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 60, "type": "EA" } }, { "description": "Oral dexamethasone", "code_information": [ { "code": "J8540", "type": "HCPCS" }, { "code": "00054-3176-44", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 30, "type": "ML" } }, { "description": "Bevacizumab injection", "code_information": [ { "code": "J9035", "type": "HCPCS" }, { "code": "50242-0060-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 4, "type": "ML" } }, { "description": "Mitomycin injection", "code_information": [ { "code": "J9280", "type": "HCPCS" }, { "code": "00143-9135-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Lumbar orthosis, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, off-the-shelf", "code_information": [ { "code": "L0625", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies", "code_information": [ { "code": "L8603", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ocular implant", "code_information": [ { "code": "L8610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prosthetic implant, not otherwise specified", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rbc leukocytes reduced", "code_information": [ { "code": "P9016", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Platelets, pheresis", "code_information": [ { "code": "P9034", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Albumin (human), 25%, 20 ml", "code_information": [ { "code": "P9046", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hocm 350-399mg/ml iodine,1ml", "code_information": [ { "code": "Q9963", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Locm 200-299mg/ml iodine,1ml", "code_information": [ { "code": "Q9966", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Locm 300-399mg/ml iodine,1ml", "code_information": [ { "code": "Q9967", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Visualization adjunct", "code_information": [ { "code": "Q9968", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Finasteride, 5 mg", "code_information": [ { "code": "S0138", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anter chamber intraocul lens", "code_information": [ { "code": "V2630", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Post chmbr intraocular lens", "code_information": [ { "code": "V2632", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Corneal tissue processing", "code_information": [ { "code": "V2785", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "USE OF HOSP,EXAM.OR TREAT.RM.", "code_information": [ { "code": "Z7500", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "USE OF EMERGENCY ROOM", "code_information": [ { "code": "Z7502", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "USE OF OPER ROOM OR CYST ROOM-FIRST HOUR", "code_information": [ { "code": "Z7506", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "USE OF OP OR CYSTO RM 1ST SUBSEQ HALF HR", "code_information": [ { "code": "Z7508", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "USE OP OR CYSTO RM SEC SUBS HALF HOUR", "code_information": [ { "code": "Z7510", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "USE OF RECOVERY ROOM", "code_information": [ { "code": "Z7512", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "PAY FOR RM AND BOARD AND GEN NURSING CAR", "code_information": [ { "code": "Z7514", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "MISC DRUGS AND MED SUPPLIES, ADMIN STAT", "code_information": [ { "code": "Z7610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "INITIAL INFANT HEAR-SCREEN-HOSP/INP", "code_information": [ { "code": "Z9725", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct perfusion w/contrast cbf", "code_information": [ { "code": "0042T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bone srgry cmptr fluor image", "code_information": [ { "code": "0054T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insj ant sgm aq drg dev 1+", "code_information": [ { "code": "0671T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth neck organ 1yr/>", "code_information": [ { "code": "00320", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth neck vessel surgery", "code_information": [ { "code": "00350", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth neck vessel surgery", "code_information": [ { "code": "00352", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth surgery of breast", "code_information": [ { "code": "00402", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth correct heart rhythm", "code_information": [ { "code": "00410", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth surgery of shoulder", "code_information": [ { "code": "00450", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth abdominal wall surg", "code_information": [ { "code": "00730", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth vasectomy", "code_information": [ { "code": "00921", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fna bx w/us gdn 1st les", "code_information": [ { "code": "10005", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "I&d abscess simple/single", "code_information": [ { "code": "10060", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "I&d abscess comp/multiple", "code_information": [ { "code": "10061", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dbrdmt subq tiss each addl", "code_information": [ { "code": "11045", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Exc tr-ext b9+marg >4.0 cm", "code_information": [ { "code": "11406", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Exc h-f-nk-sp b9+marg 1.1-2", "code_information": [ { "code": "11422", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr s/n/ax/gen/trnk 2.5cm/<", "code_information": [ { "code": "12001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr s/n/ax/gen/trnk2.6-7.5cm", "code_information": [ { "code": "12002", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr s/n/ax/gen/trk7.6-12.5cm", "code_information": [ { "code": "12004", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr f/e/e/n/l/m 2.5 cm/<", "code_information": [ { "code": "12011", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr f/e/e/n/l/m 2.6-5.0 cm", "code_information": [ { "code": "12013", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intmd rpr s/a/t/ext 2.6-7.5", "code_information": [ { "code": "12032", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tis trnfr trunk 10 sq cm/<", "code_information": [ { "code": "14000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tis trnfr s/a/l 10 sq cm/<", "code_information": [ { "code": "14020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Grfg autol fat lipo 50 cc/<", "code_information": [ { "code": "15771", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Grfg autol fat lipo ea addl", "code_information": [ { "code": "15772", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal sutr/stapl xreq anes", "code_information": [ { "code": "15853", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dress/debrid p-thick burn s", "code_information": [ { "code": "16020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bx breast 1st lesion strtctc", "code_information": [ { "code": "19081", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bx breast 1st lesion us imag", "code_information": [ { "code": "19083", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal of breast lesion", "code_information": [ { "code": "19120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Perq device breast 1st imag", "code_information": [ { "code": "19281", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Perq dev breast 1st us imag", "code_information": [ { "code": "19285", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Partial mastectomy", "code_information": [ { "code": "19301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "P-mastectomy w/ln removal", "code_information": [ { "code": "19302", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mast simple complete", "code_information": [ { "code": "19303", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mast mod rad", "code_information": [ { "code": "19307", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bone biopsy trocar/ndl deep", "code_information": [ { "code": "20225", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Drain/inj joint/bursa w/o us", "code_information": [ { "code": "20610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal of implant deep", "code_information": [ { "code": "20680", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cptr-asst dir ms px", "code_information": [ { "code": "20985", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Exc face tum deep 2 cm/>", "code_information": [ { "code": "21014", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Exc neck les sc 3 cm/>", "code_information": [ { "code": "21552", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Exc back les sc 3 cm/>", "code_information": [ { "code": "21931", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Osteot dsc ant 1vrt sgm lmbr", "code_information": [ { "code": "22224", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Perq vertebral augmentation", "code_information": [ { "code": "22513", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Perq vertebral augmentation", "code_information": [ { "code": "22514", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Perq vertebral augmentation", "code_information": [ { "code": "22515", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Arthrd ant toral/xoral c1-c2", "code_information": [ { "code": "22548", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Arthrd ant ntrbd cervical ea", "code_information": [ { "code": "22552", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Repair rotator cuff chronic", "code_information": [ { "code": "23412", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Optx clavicular fx w/int fix", "code_information": [ { "code": "23515", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cltx sho dslc w/mnpj wo anes", "code_information": [ { "code": "23650", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reconstruct elbow lat ligmnt", "code_information": [ { "code": "24344", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Repair of humerus", "code_information": [ { "code": "24430", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat humerus fracture", "code_information": [ { "code": "24516", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat elbow dislocation", "code_information": [ { "code": "24615", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat ulnar fracture", "code_information": [ { "code": "24685", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat fx rad extra-articul", "code_information": [ { "code": "25607", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat fx rad intra-articul", "code_information": [ { "code": "25608", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat fracture ulnar styloid", "code_information": [ { "code": "25652", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat thumb fracture", "code_information": [ { "code": "26645", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Total hip arthroplasty", "code_information": [ { "code": "27130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Revision of unstable kneecap", "code_information": [ { "code": "27422", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lat retinacular release open", "code_information": [ { "code": "27425", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reconstruction knee", "code_information": [ { "code": "27427", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Revision of knee joint", "code_information": [ { "code": "27446", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Total knee arthroplasty", "code_information": [ { "code": "27447", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat kneecap fracture", "code_information": [ { "code": "27524", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fixation of knee joint", "code_information": [ { "code": "27570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reconstruction ankle joint", "code_information": [ { "code": "27703", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Realignment of lower leg", "code_information": [ { "code": "27712", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Part removal of metatarsal", "code_information": [ { "code": "28110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Repair of hammertoe", "code_information": [ { "code": "28285", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat/graft heel fracture", "code_information": [ { "code": "28420", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Apply long arm splint", "code_information": [ { "code": "29105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Application long leg splint", "code_information": [ { "code": "29505", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Application lower leg splint", "code_information": [ { "code": "29515", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sho arthrs dx +- synovial bx", "code_information": [ { "code": "29805", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sho arthrs srg lmtd dbrdmt", "code_information": [ { "code": "29822", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sho arthrs srg decompression", "code_information": [ { "code": "29826", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sho arthrs srg rt8tr cuf rpr", "code_information": [ { "code": "29827", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tib/per revasc add-on", "code_information": [ { "code": "37232", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tibper revasc w/ather add-on", "code_information": [ { "code": "37233", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Open/perq place stent same", "code_information": [ { "code": "37238", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Open/perq place stent ea add", "code_information": [ { "code": "37239", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vasc embolize/occlude organ", "code_information": [ { "code": "37243", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Trluml balo angiop 1st art", "code_information": [ { "code": "37246", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intrvasc us noncoronary 1st", "code_information": [ { "code": "37252", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intrvasc us noncoronary addl", "code_information": [ { "code": "37253", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Phleb veins - extrem 20+", "code_information": [ { "code": "37766", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dx bone marrow bx & aspir", "code_information": [ { "code": "38222", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Biopsy/removal lymph nodes", "code_information": [ { "code": "38500", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Needle biopsy lymph nodes", "code_information": [ { "code": "38505", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Biopsy/removal lymph nodes", "code_information": [ { "code": "38525", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Open bx/exc inguinofem nodes", "code_information": [ { "code": "38531", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopy lymph node biop", "code_information": [ { "code": "38570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopy lymphadenectomy", "code_information": [ { "code": "38571", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Io map of sent lymph node", "code_information": [ { "code": "38900", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove tonsils and adenoids", "code_information": [ { "code": "42821", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal of tonsils", "code_information": [ { "code": "42826", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Egd diagnostic brush wash", "code_information": [ { "code": "43235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Egd biopsy single/multiple", "code_information": [ { "code": "43239", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Egd varices ligation", "code_information": [ { "code": "43244", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sho arthrs srg bicp tenodsis", "code_information": [ { "code": "29828", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Knee arthroscopy/surgery", "code_information": [ { "code": "29880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Knee arthroscopy/surgery", "code_information": [ { "code": "29881", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Excise inferior turbinate", "code_information": [ { "code": "30130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Resect inferior turbinate", "code_information": [ { "code": "30140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Repair of nasal septum", "code_information": [ { "code": "30520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ablate inf turbinate superf", "code_information": [ { "code": "30801", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nsl/sins ndsc surg bx polypc", "code_information": [ { "code": "31237", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nsl/sins ndsc w/prtl ethmdct", "code_information": [ { "code": "31254", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Exploration maxillary sinus", "code_information": [ { "code": "31256", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nsl/sins ndsc tot w/sphendt", "code_information": [ { "code": "31257", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nsl/sins ndsc sphn tiss rmvl", "code_information": [ { "code": "31259", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Endoscopy maxillary sinus", "code_information": [ { "code": "31267", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nsl/sins ndsc frnt tiss rmvl", "code_information": [ { "code": "31276", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nasal/sinus endoscopy surg", "code_information": [ { "code": "31288", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insert emergency airway", "code_information": [ { "code": "31500", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Core ndl bx lng/med perq", "code_information": [ { "code": "32408", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Aspirate pleura w/ imaging", "code_information": [ { "code": "32555", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insert heart pm ventricular", "code_information": [ { "code": "33207", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove&replace pm gen singl", "code_information": [ { "code": "33227", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remv&replc pm gen dual lead", "code_information": [ { "code": "33228", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Place catheter in vein", "code_information": [ { "code": "36012", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Place catheter in aorta", "code_information": [ { "code": "36200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Place cath subclavian art", "code_information": [ { "code": "36225", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ins cath abd/l-ext art 3rd", "code_information": [ { "code": "36247", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ins cath abd/l-ext art addl", "code_information": [ { "code": "36248", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Routine venipuncture", "code_information": [ { "code": "36415", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Transfusion bld/bld compnt", "code_information": [ { "code": "36430", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intrauterine transfusion ftl", "code_information": [ { "code": "36460", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Apheresis plasma", "code_information": [ { "code": "36514", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insert non-tunnel cv cath", "code_information": [ { "code": "36556", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insert tunneled cv cath", "code_information": [ { "code": "36558", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insert tunneled cv cath", "code_information": [ { "code": "36561", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insj picc 5 yr+ w/o imaging", "code_information": [ { "code": "36569", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insj picc rs&i 5 yr+", "code_information": [ { "code": "36573", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal tunneled cv cath", "code_information": [ { "code": "36589", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal tunneled cv cath", "code_information": [ { "code": "36590", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reposition venous catheter", "code_information": [ { "code": "36597", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Withdrawal of arterial blood", "code_information": [ { "code": "36600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Av fuse uppr arm basilic", "code_information": [ { "code": "36819", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Av fusion direct any site", "code_information": [ { "code": "36821", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Artery-vein nonautograft", "code_information": [ { "code": "36830", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Av fistula revision open", "code_information": [ { "code": "36832", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intro cath dialysis circuit", "code_information": [ { "code": "36901", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intro cath dialysis circuit", "code_information": [ { "code": "36902", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intro cath dialysis circuit", "code_information": [ { "code": "36903", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Thrmbc/nfs dialysis circuit", "code_information": [ { "code": "36905", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Thrmbc/nfs dialysis circuit", "code_information": [ { "code": "36906", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Balo angiop ctr dialysis seg", "code_information": [ { "code": "36907", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dialysis circuit embolj", "code_information": [ { "code": "36909", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rem endovas vena cava filter", "code_information": [ { "code": "37193", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Thrombolytic art therapy", "code_information": [ { "code": "37211", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fem/popl revas w/tla", "code_information": [ { "code": "37224", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fem/popl revas w/ather", "code_information": [ { "code": "37225", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tib/per revasc w/tla", "code_information": [ { "code": "37228", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Egd place gastrostomy tube", "code_information": [ { "code": "43246", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopy fundoplasty", "code_information": [ { "code": "43280", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reposition gastrostomy tube", "code_information": [ { "code": "43761", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rplc gtube no revj trc", "code_information": [ { "code": "43762", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopy appendectomy", "code_information": [ { "code": "44970", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Proctosigmoidoscopy dx", "code_information": [ { "code": "45300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Diagnostic colonoscopy", "code_information": [ { "code": "45378", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Colonoscopy and biopsy", "code_information": [ { "code": "45380", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Colonoscopy submucous njx", "code_information": [ { "code": "45381", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Colonoscopy w/lesion removal", "code_information": [ { "code": "45385", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Colonoscopy w/ablation", "code_information": [ { "code": "45388", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove int/ext hem 1 group", "code_information": [ { "code": "46255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove in/ex hem groups 2+", "code_information": [ { "code": "46260", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Diagnostic anoscopy & biopsy", "code_information": [ { "code": "46607", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Destruction anal lesion(s)", "code_information": [ { "code": "46924", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Needle biopsy of liver", "code_information": [ { "code": "47000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopic cholecystectomy", "code_information": [ { "code": "47562", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparo cholecystectomy/graph", "code_information": [ { "code": "47563", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Abd paracentesis w/imaging", "code_information": [ { "code": "49083", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopy aspiration", "code_information": [ { "code": "49322", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lap insert tunnel ip cath", "code_information": [ { "code": "49324", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove tunneled ip cath", "code_information": [ { "code": "49422", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prp i/hern init reduc >5 yr", "code_information": [ { "code": "49505", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prp i/hern init block >5 yr", "code_information": [ { "code": "49507", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rerepair ing hernia reduce", "code_information": [ { "code": "49520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr aa hrn 1st < 3 cm rdc", "code_information": [ { "code": "49591", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr aa hrn 1st < 3 ncr/strn", "code_information": [ { "code": "49592", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr aa hrn 1st 3-10 ncr/strn", "code_information": [ { "code": "49594", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lap ing hernia repair init", "code_information": [ { "code": "49650", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lap ing hernia repair recur", "code_information": [ { "code": "49651", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Exchange nephrostomy cath", "code_information": [ { "code": "50435", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparo partial nephrectomy", "code_information": [ { "code": "50543", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fragmenting of kidney stone", "code_information": [ { "code": "50590", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Unlisted laps px ureter", "code_information": [ { "code": "50949", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Drain bl w/cath insertion", "code_information": [ { "code": "51102", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insert temp bladder cath", "code_information": [ { "code": "51702", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Us urine capacity measure", "code_information": [ { "code": "51798", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cystoscopy w/biopsy(s)", "code_information": [ { "code": "52204", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52224", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52234", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52240", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52310", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove bladder stone", "code_information": [ { "code": "52317", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52332", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cysto/uretero w/lithotripsy", "code_information": [ { "code": "52356", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prostatectomy (turp)", "code_information": [ { "code": "52601", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insert uro/ves nck sphincter", "code_information": [ { "code": "53445", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Circum 28 days or older", "code_information": [ { "code": "54161", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal of hydrocele", "code_information": [ { "code": "55040", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Biopsy of prostate", "code_information": [ { "code": "55700", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Abltj mal prst8 tiss hifu", "code_information": [ { "code": "55880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cmbn ant pst colprhy", "code_information": [ { "code": "57260", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Repair bladder defect", "code_information": [ { "code": "57288", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Conz of cervix w/scope leep", "code_information": [ { "code": "57461", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Conization of cervix", "code_information": [ { "code": "57522", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dilation and curettage", "code_information": [ { "code": "58120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove intrauterine device", "code_information": [ { "code": "58301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparo-asst vag hysterectomy", "code_information": [ { "code": "58550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparo-vag hyst incl t/o", "code_information": [ { "code": "58552", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparo-vag hyst w/t/o compl", "code_information": [ { "code": "58554", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hysteroscopy biopsy", "code_information": [ { "code": "58558", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hysteroscopy remove myoma", "code_information": [ { "code": "58561", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hysteroscopy ablation", "code_information": [ { "code": "58563", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tlh uterus 250 g or less", "code_information": [ { "code": "58570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tlh w/t/o 250 g or less", "code_information": [ { "code": "58571", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopy remove adnexa", "code_information": [ { "code": "58661", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopy excise lesions", "code_information": [ { "code": "58662", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fetal cord puncture prenatal", "code_information": [ { "code": "59012", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fetal non-stress test", "code_information": [ { "code": "59025", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Care of miscarriage", "code_information": [ { "code": "59820", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Unlisted fetal invas px w/us", "code_information": [ { "code": "59897", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Partial removal of thyroid", "code_information": [ { "code": "60220", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Scan proc cranial extra", "code_information": [ { "code": "61782", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dx lmbr spi pnxr", "code_information": [ { "code": "62270", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dx lmbr spi pnxr w/fluor/ct", "code_information": [ { "code": "62328", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Njx aa&/strd other pn/branch", "code_information": [ { "code": "64450", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Revise ulnar nerve at elbow", "code_information": [ { "code": "64718", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Carpal tunnel surgery", "code_information": [ { "code": "64721", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal of eye lesion", "code_information": [ { "code": "65426", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Corneal transplant", "code_information": [ { "code": "65730", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Corneal transplant", "code_information": [ { "code": "65755", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Corneal trnspl endothelial", "code_information": [ { "code": "65756", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Relieve inner eye pressure", "code_information": [ { "code": "65820", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Glaucoma surgery", "code_information": [ { "code": "66170", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Aqueous shunt eye w/graft", "code_information": [ { "code": "66180", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Follow-up surgery of eye", "code_information": [ { "code": "66250", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Incision of iris", "code_information": [ { "code": "66500", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal of iris", "code_information": [ { "code": "66625", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal of iris", "code_information": [ { "code": "66630", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "After cataract laser surgery", "code_information": [ { "code": "66821", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Xcapsl ctrc rmvl cplx wo ecp", "code_information": [ { "code": "66982", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Xcapsl ctrc rmvl w/o ecp", "code_information": [ { "code": "66984", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Xcapsl ctrc rmvl insj 1+", "code_information": [ { "code": "66991", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection eye drug", "code_information": [ { "code": "67028", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dstrj extensive retinopathy", "code_information": [ { "code": "67227", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reinforce/graft eye wall", "code_information": [ { "code": "67255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove eyelid lesion", "code_information": [ { "code": "67800", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove impacted ear wax uni", "code_information": [ { "code": "69209", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of nasal bones", "code_information": [ { "code": "70160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of neck", "code_information": [ { "code": "70360", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct head/brain w/o dye", "code_information": [ { "code": "70450", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct orbit/ear/fossa w/o dye", "code_information": [ { "code": "70480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct maxillofacial w/o dye", "code_information": [ { "code": "70486", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct maxillofacial w/dye", "code_information": [ { "code": "70487", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct soft tissue neck w/o dye", "code_information": [ { "code": "70490", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct soft tissue neck w/dye", "code_information": [ { "code": "70491", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angiography head", "code_information": [ { "code": "70496", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angiography neck", "code_information": [ { "code": "70498", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri brain stem w/o dye", "code_information": [ { "code": "70551", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri brain stem w/o & w/dye", "code_information": [ { "code": "70553", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam ribs uni 2 views", "code_information": [ { "code": "71100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam unilat ribs/chest", "code_information": [ { "code": "71101", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam ribs bil 3 views", "code_information": [ { "code": "71110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam ribs/chest4/> vws", "code_information": [ { "code": "71111", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct thorax dx c-", "code_information": [ { "code": "71250", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct thorax dx c+", "code_information": [ { "code": "71260", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angiography chest", "code_information": [ { "code": "71275", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of spine 1 view", "code_information": [ { "code": "72020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam neck spine 2-3 vw", "code_information": [ { "code": "72040", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam neck spine 4/5vws", "code_information": [ { "code": "72050", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam thorac spine 2vws", "code_information": [ { "code": "72070", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam thorac spine 3vws", "code_information": [ { "code": "72072", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam l-s spine 2/3 vws", "code_information": [ { "code": "72100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam l-2 spine 4/>vws", "code_information": [ { "code": "72110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct neck spine w/o dye", "code_information": [ { "code": "72125", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct chest spine w/o dye", "code_information": [ { "code": "72128", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct lumbar spine w/o dye", "code_information": [ { "code": "72131", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri neck spine w/o dye", "code_information": [ { "code": "72141", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri chest spine w/o dye", "code_information": [ { "code": "72146", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri lumbar spine w/o dye", "code_information": [ { "code": "72148", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri neck spine w/o & w/dye", "code_information": [ { "code": "72156", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angiograph pelv w/o&w/dye", "code_information": [ { "code": "72191", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct pelvis w/o dye", "code_information": [ { "code": "72192", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct pelvis w/dye", "code_information": [ { "code": "72193", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri pelvis w/o dye", "code_information": [ { "code": "72195", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri pelvis w/o & w/dye", "code_information": [ { "code": "72197", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam sacrum tailbone", "code_information": [ { "code": "72220", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of collar bone", "code_information": [ { "code": "73000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of shoulder", "code_information": [ { "code": "73020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of humerus", "code_information": [ { "code": "73060", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of elbow", "code_information": [ { "code": "73070", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of elbow", "code_information": [ { "code": "73080", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of forearm", "code_information": [ { "code": "73090", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of wrist", "code_information": [ { "code": "73110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of hand", "code_information": [ { "code": "73120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of hand", "code_information": [ { "code": "73130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of finger(s)", "code_information": [ { "code": "73140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct upper extremity w/o dye", "code_information": [ { "code": "73200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri joint upr extrem w/o dye", "code_information": [ { "code": "73221", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam hip uni 1 view", "code_information": [ { "code": "73501", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam hip uni 2-3 views", "code_information": [ { "code": "73502", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam hip uni 4/> views", "code_information": [ { "code": "73503", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam hips bi 2 views", "code_information": [ { "code": "73521", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam hips bi 3-4 views", "code_information": [ { "code": "73522", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of femur 1", "code_information": [ { "code": "73551", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of femur 2/>", "code_information": [ { "code": "73552", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of knee 3", "code_information": [ { "code": "73562", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam knee 4 or more", "code_information": [ { "code": "73564", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of knees", "code_information": [ { "code": "73565", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of lower leg", "code_information": [ { "code": "73590", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of ankle", "code_information": [ { "code": "73600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of foot", "code_information": [ { "code": "73620", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of foot", "code_information": [ { "code": "73630", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of toe(s)", "code_information": [ { "code": "73660", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct lower extremity w/o dye", "code_information": [ { "code": "73700", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct lower extremity w/dye", "code_information": [ { "code": "73701", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri jnt of lwr extre w/o dye", "code_information": [ { "code": "73721", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam complete abdomen", "code_information": [ { "code": "74022", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct abdomen w/o dye", "code_information": [ { "code": "74150", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct abdomen w/o & w/dye", "code_information": [ { "code": "74170", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angio abd&pelv w/o&w/dye", "code_information": [ { "code": "74174", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angio abdom w/o & w/dye", "code_information": [ { "code": "74175", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct abd & pelvis w/o contrast", "code_information": [ { "code": "74176", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct abd & pelv 1/> regns", "code_information": [ { "code": "74178", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri abdomen w/o dye", "code_information": [ { "code": "74181", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri abdomen w/o & w/dye", "code_information": [ { "code": "74183", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray xm swlng funcj c+", "code_information": [ { "code": "74230", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray xm sm int 1cntrst std", "code_information": [ { "code": "74250", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray bile/panc endoscopy", "code_information": [ { "code": "74330", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angio hrt w/3d image", "code_information": [ { "code": "75574", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray aorta leg arteries", "code_information": [ { "code": "75630", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angio abdominal arteries", "code_information": [ { "code": "75635", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Artery x-rays arms/legs", "code_information": [ { "code": "75716", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Artery x-rays abdomen", "code_information": [ { "code": "75726", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vein x-ray arm/leg", "code_information": [ { "code": "75820", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vein x-ray arms/legs", "code_information": [ { "code": "75822", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vein x-ray trunk", "code_information": [ { "code": "75825", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vein x-ray chest", "code_information": [ { "code": "75827", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fluoroscopy <1 hr phys/qhp", "code_information": [ { "code": "76000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam surgical specimen", "code_information": [ { "code": "76098", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cat scan follow-up study", "code_information": [ { "code": "76380", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Echo exam of eye thickness", "code_information": [ { "code": "76514", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Us exam of head and neck", "code_information": [ { "code": "76536", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ultrasound breast complete", "code_information": [ { "code": "76641", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Echo exam of abdomen", "code_information": [ { "code": "76705", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Us exam abdo back wall comp", "code_information": [ { "code": "76770", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ob us < 14 wks single fetus", "code_information": [ { "code": "76801", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ob us >= 14 wks sngl fetus", "code_information": [ { "code": "76805", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ob us detailed sngl fetus", "code_information": [ { "code": "76811", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ob us limited fetus(s)", "code_information": [ { "code": "76815", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Transvaginal us obstetric", "code_information": [ { "code": "76817", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fetal biophys profile w/nst", "code_information": [ { "code": "76818", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fetal biophys profil w/o nst", "code_information": [ { "code": "76819", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Transvaginal us non-ob", "code_information": [ { "code": "76830", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Us exam pelvic complete", "code_information": [ { "code": "76856", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Us exam scrotum", "code_information": [ { "code": "76870", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Us transrectal", "code_information": [ { "code": "76872", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Us guide vascular access", "code_information": [ { "code": "76937", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Echo guide for transfusion", "code_information": [ { "code": "76941", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Echo guide for biopsy", "code_information": [ { "code": "76942", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Echo examination procedure", "code_information": [ { "code": "76999", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fluoroguide for vein device", "code_information": [ { "code": "77001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Needle localization by xray", "code_information": [ { "code": "77002", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct scan for needle biopsy", "code_information": [ { "code": "77012", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dx mammo incl cad uni", "code_information": [ { "code": "77065", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dx mammo incl cad bi", "code_information": [ { "code": "77066", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Scr mammo bi incl cad", "code_information": [ { "code": "77067", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dxa bone density axial", "code_information": [ { "code": "77080", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Set radiation therapy field", "code_information": [ { "code": "77280", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Set radiation therapy field", "code_information": [ { "code": "77290", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "3-d radiotherapy plan", "code_information": [ { "code": "77295", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiation therapy dose plan", "code_information": [ { "code": "77300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Telethx isodose plan cplx", "code_information": [ { "code": "77307", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiation treatment aid(s)", "code_information": [ { "code": "77332", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiation treatment aid(s)", "code_information": [ { "code": "77334", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiation physics consult", "code_information": [ { "code": "77336", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Design mlc device for imrt", "code_information": [ { "code": "77338", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ntsty modul rad tx dlvr cplx", "code_information": [ { "code": "77386", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiation treatment delivery", "code_information": [ { "code": "77412", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology port images(s)", "code_information": [ { "code": "77417", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Thyroid met imaging body", "code_information": [ { "code": "78018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hepatobiliary system imaging", "code_information": [ { "code": "78226", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Gastric emptying imag study", "code_information": [ { "code": "78264", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bone imaging whole body", "code_information": [ { "code": "78306", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ht muscle image spect sing", "code_information": [ { "code": "78451", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ht muscle image spect mult", "code_information": [ { "code": "78452", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lipid panel", "code_information": [ { "code": "80061", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Acute hepatitis panel", "code_information": [ { "code": "80074", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hepatic function panel", "code_information": [ { "code": "80076", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Drug assay acetaminophen", "code_information": [ { "code": "80143", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of digoxin free", "code_information": [ { "code": "80163", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dipropylacetic acid free", "code_information": [ { "code": "80165", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Drug scrn quan levetiracetam", "code_information": [ { "code": "80177", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Drug assay salicylate", "code_information": [ { "code": "80179", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of phenobarbital", "code_information": [ { "code": "80184", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of phenytoin total", "code_information": [ { "code": "80185", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Drug test prsmv dir opt obs", "code_information": [ { "code": "80305", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Drug test prsmv chem anlyzr", "code_information": [ { "code": "80307", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Urinalysis auto w/o scope", "code_information": [ { "code": "81003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Microscopic exam of urine", "code_information": [ { "code": "81015", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Urine pregnancy test", "code_information": [ { "code": "81025", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Acetone assay", "code_information": [ { "code": "82010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of serum albumin", "code_information": [ { "code": "82040", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Alpha-fetoprotein serum", "code_information": [ { "code": "82105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of ammonia", "code_information": [ { "code": "82140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of amylase", "code_information": [ { "code": "82150", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of beta-2 protein", "code_information": [ { "code": "82232", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bilirubin direct", "code_information": [ { "code": "82248", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Occult bld feces 1-3 tests", "code_information": [ { "code": "82272", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vitamin d 25 hydroxy", "code_information": [ { "code": "82306", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Calculus assay quant", "code_information": [ { "code": "82360", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Carcinoembryonic antigen", "code_information": [ { "code": "82378", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Total cortisol", "code_information": [ { "code": "82533", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of ck (cpk)", "code_information": [ { "code": "82550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Creatine mb fraction", "code_information": [ { "code": "82553", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of creatinine", "code_information": [ { "code": "82565", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of urine creatinine", "code_information": [ { "code": "82570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vitamin b-12", "code_information": [ { "code": "82607", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of erythropoietin", "code_information": [ { "code": "82668", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of folic acid serum", "code_information": [ { "code": "82746", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay iga/igd/igg/igm each", "code_information": [ { "code": "82784", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay glucose blood quant", "code_information": [ { "code": "82947", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of ggt", "code_information": [ { "code": "82977", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Regence Blue Cross Blue Shield", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of haptoglobin quant", "code_information": [ { "code": "83010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data availa